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Diverticulosis Coli .

Dr.Barin Bose MS,FACRSI, FAIS.

Consultant Surgeon and Coloproctologist.

Jabalpur Hospital and Research Centre.

Jabalpur (M.P.)

The condition is common in those countries where diatery fibres is replaced by charbohydrates. In Western counteries the roughage has been removed from flour and refined sugar form a large part of the diet, diverticula are found in 25% of barium enema of patients over the age of 40 years and the incidence increases with age. Diverticular diseases is rare in Africans and Asians who eats a diet that contains natural fibres. So diverticulosis is the disease of Western countery. The disease is found 30% in the age of 60 years and 80% in the age of 80 years.

Diverticulum – A single out pocketing, diverticula means multiple out pocketing and Diverticulosis is the disease , it means the presence of diverticula or diverticulum.

Diverticulitis means inflammation of one or more diverticula . Diverticula is the outpouching of mucosa and submucosa through weaknes in the muscular layer of the colon, where the neutrent artery enters the colon.It is a pseudo diverticula as it do not contains the muscular coat of the colon. True diverticulosis is rare in colon.

Increased intrarectal pressure is the cause as patients having diverticular disease are seem to be habitually constipated.

Diverticula can occur any where in the GIT. In oesophagus diverticula can cause dysphagia. Diverticulum of stomach and duodenum are asymptomatic, diverticulum of small intestine predisposes to bacterial overgrowth and malabsorption. 90% of the patients with diverticula remains asymptomatic. But because of high prevalence of this condition diverticular disease occur frequently.

Most diverticulum are found in sigmoid colon, but diverticulum can be found in proximal colon also. Caecun can be involved, sometime entire large bowel is affected but rectum is never affected. In 90% of cases sigmoid is involved and almost always it is the site of diverticulitis. As 90% of cases of diverticulosis are asymptomatic, but when symptomatic paients complaints of lower abdominal pain, infrequent bowel movement or constipation. In many cases symptoms of IBS is indifferentiated from diverticular disease.

On examination it reveals tender firm fecal filled sigmoid colon in left lower abdomen. Diagnostic studies are required if the patient have anorexia, weight loss and blood in stools. Investigations include complete blood count , barium enema studies, sigmoidoscopy and colonoscopy.

Differential diagnosis – The condition should be differentiated from IBS, Ca colon and inflammatory bowel disease.

 

Treatment - In uncomplicated and asymptomatic diverticular disease the treatment is same as IBS. Diverticulosis is treated by high residue diet, this is done by increasing fibre in the diet, a high fibre diet has been shown to alleviate the discomfort of diverticular disease. Fibre also can be added in the form of bran and other bulk forming laxatives.

Antispasmodic as Dicyclomine hydrochloride may be useful in the treatment of crampy abdominal pain. Cathartic laxatives should be avoided.

Diverticulitis : Fully developed divericulitis presents as acute lower abdominal pain, fever, tachycardia. The lower abdomen is tender to palpation and there may be rebound tenderness indicating peritonitis. A mass in the lower abdomen may indicate the presence of abscess.Bowel sounds may be active in the presence of obstruction or they may be hypoactive or abscent if peritonitis has developed. A rectal examination may reveal the abscess or inflammatory mass.

Complications of Diverticulosis –

(1) Recurrent attacks of diverticulitis leading to pain in abdomen.

(2) Perforation leading to gereralised peritonitis or local abscess formation.

(3) Intestinal obstruction –

(a) Obstruction in the sigmoid due to progressive fibrosis and stenosis.

(b)Obstruction in the small intestine (which is more common) is due to adhesion of the loops of small intestine on the pericolitis.

(4) Haemorrhage –Diverticulitis may present with profuse colonic haemorrhage in 17% of cases, which often requires blood transfusion.

(5) Fistuila formation – vesico-colic,vagino-colic, entero-colic and colo-colic fistula occur in 5% of cases, vesico-colic fistula being the most common.

Diagnostic studies – (a) Blood studies- The white blood cell count is elevated in acute diverticulitis. (b) Urine analysis – Shows the presence of white blood cells and red blood cells. An unusual complication of diverticulitis is colovesical fistula, in this condition the urine contains a large number of white blood cells and bacteria. Patients may complaints of pneumaturia. (c) Plain X Ray abdomen in standing position shows multiple fluid levels indicating obstruction. Free air under the diaphragm indicates perforation. (d) CT abdomen and / or USG – May reveal abscess cavity or inflammatory mass. (e) Sigmoidoscopy,Colonoscopy and barium enema XRay examination. Sigmoidoscopy or colonoscopy may be performed cautiously if perforation is not suspected. However it is best to delay these tests until symptoms have subsided.

Treatment – Patients with severe acute diverticulitis are best treated by allowing nothing by mouth, nasogastric aspiration and administration of intravenous fluids and electrolytes. Intravenous broad spectrum antibiotics such as the combination of Ampicilline and Gentamicin and more recently Ciprofloxacin or Metronidazole are indicated and should be continued for 10 to 14 days.

Surgery - Most patients with uncomplicated diverticulitis recover with medical treatment and do not have recurrence of acute disease. Surgery is not recommended. But unresolved obstruction and colo-vesical fistula are indications for surgical treatment.

However failure to improve after several days of conservative treatment or if recurrence occur after successful treatment are indication for surgery.

Some 10% of patients require an operation either for recurrent attacks which make life a misery or for the complications of diverticulitis.

  1. The ideal operation is carried out as an interval procedure, after careful preparation of the gut, is a one-stage resection. This involves removal of the affected segment of gut and restoration of the continuity by end to end anastomosis and with or without proximal defunctioning colostomy. At this operation the sigmoid loop is often found adherent in the pouch of Douglas.Careful dissection of the recto-sigmoid out of the pelvis will allow an easier anastomosis.
  2. If there is obstruction , inflammatory edema and adhesion or the bowel is loaded with fecal matter – Hartmann’s operation is the procedure of choice. The involved area is resected , the rectum is closed at the peritoneal reflection and the left colon is brought out at the left iliac fossa as an end colostomy.
  3. In the presence of perforation and gross fecal peritonitis, the following procedures can be considered –
        1. Primary resection and Hartmann’s procedure.
        2. Primary resection and anastomosis after doing an on-table bowel lavage.
        3. Exteriorisation of the affected bowel which is opened as colostomy followed by resection and anastomosis after three months.
        4. Suture of the perforation with drainage and with or without proximal defunctioning colostomy.
  4. In the case of colo-vesical fistila it is possible to pinch off the affected bowel from the bladder. Resect the sigmoid and do an end to end anastomosis with a proximal defunctioning colostomy , closure of the colostomy is done in the later date.

Diverticular Bleeding - Is one of the most common cause of lower gastrointestinal bleeding in older patients. But a diverticular bleeding and acute diverticulitis rarely coexist. However it is likely that some degree of peridiverticular inflammation is present in patients who bleed from diverticula. It usually responds to conservative management and occasionally requires resection.

Diverticular Disease and Carcinoma – In 12 % of the cases diverticular disease and carcinoma coexist. It can be differentiated by - (a) weight loss (b) falling haemoglobin (c) Persistently positive occult blood in stools.